護理師照護一位有壓瘡風險的病人。護理計畫應包含下列哪些措施？（選所有適合的）
A nurse is caring for a client who is at risk for developing a pressure injury. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
- AReposition the client every 2 hours✓ 正解每 2 小時重新安置客戶姿勢
- BKeep the skin clean and dry✓ 正解保持皮膚清潔乾燥
- CMassage the bony prominences按摩骨突處
- DApply a moisture barrier cream✓ 正解塗抹濕氣屏障乳霜
- EElevate the head of the bed to 45 degrees將床頭抬高至 45 度
預防壓瘡的核心在於減壓、皮膚護理與水分管理。每兩小時翻身是減壓金標準，保持皮膚清潔乾燥可預防浸潤。按摩骨突處已證實會損傷皮下組織，應避免。床頭角度不宜超過 30 度以防剪力（Shearing），45 度會增加此風險。保護霜則能減少皮膚與排泄物接觸造成的刺激。
Pressure ulcer prevention centers on pressure relief, skin care, and moisture management. Repositioning every two hours is the gold standard for pressure relief, and keeping skin clean and dry prevents maceration. Massage over bony prominences has been shown to damage subcutaneous tissue and should be avoided. The head of the bed should not be elevated beyond 30 degrees to prevent shearing; 45 degrees increases this risk. Barrier creams help reduce irritation from contact between the skin and excreta.
美國護理常使用氣墊床與減壓敷料，台灣健保對減壓器材申請較嚴格，需符合特定等級評估。